- Jane Feinmann, freelance journalist
When Majid, a 15 year old Pakistani labourer, was hit by a tractor, he was unable to afford the surgery he urgently needed. As the sole financial supporter for his widowed mother and younger siblings, he needed to regain full mobility and get back to work. And thanks to Heartfile Health Financing, today Majid is on the road to a full recovery.
Heartfile Health Financing (www.heartfilefinancing.org) is an innovative and ambitious system that uses mobile phones to trigger the speedy transfer of philanthropic funds to patients who need them. Sania Nishtar, a 49 year old doctor and anticorruption campaigner who founded the non-governmental organisation Heartfile, the think tank that launched the funding system in 2010, has united two of Pakistan’s strengths: its high levels of philanthropy and mobile phone ownership. Under the scheme, volunteer doctors report needy patients to the Heartfile team, who then use an online system to register the patient, approve the requests, and organise payments for their treatment—all within a matter of days. The technological infrastructure of the scheme is designed to be transparent in order to help curb the corruption that is widely acknowledged to be a major obstacle to equitable healthcare in Pakistan.
In London recently to address a parliamentary seminar in the House of Lords, Nishtar told me how she came to devise and launch the scheme in Pakistan, where maternal mortality, unwanted pregnancies, and risk factors for heart disease all remain high. Pakistan is also one of just four countries in the world where polio has not been eradicated.
A member of the Royal College of Physicians, Nishtar became Pakistan’s first female cardiologist in 1996. Within four years, however, she had left not just her job but also the profession—a decision driven by her team being ordered to re-use catheters when treating non-paying patients. “In Pakistan you palpate poverty every day, but I have never been able to take it for granted,” she explains. “I was brought up to believe in equality—and though people said I was insane to give up a thriving medical career, I could not live with this two tier system.”
She started Heartfile from scratch, mobilising a grant from the Canadian National Development Agency to produce a set of patient information pamphlets for Pakistani patients based on British Heart Foundation publications. When an evaluation of the project, published in the International Journal of Communication,1 showed that knowledge levels had risen but behaviour had not changed, she began to lobby the government to develop a national plan for non-communicable diseases—a process she led in 2003, at the same time enrolling to do a PhD in heart disease in Pakistan at King’s College, London.
In 2006, she wrote the “Gateway paper” (www.heartfile.org/gateway.htm), an analysis of Pakistan’s mixed health systems, following it in 2007 with Gateway paper II, the first compendium of the country’s health statistics, providing an analysis of the hundreds of initiatives to reform healthcare in the country since its creation. For Nishtar, it was also “a rude shock to realise that so many well meaning national and internationals plans had been stalled by lack of policy consistency and corruption,” she recalls.
Her book, Choked Pipes,2 dissects the institutionalised malpractice and corruption in healthcare, documenting in detail the administrative corruption that enables pilfering of state resources and charging for services that are intended to be free. “Managerial reluctance to confront physicians in public hospitals,” she writes, results in “deliberate lack of oversight and inattention . . . one of the more pronounced ways in which senior public officials in Pakistan fail to compel accountability.” Detailed tables show how subsidies and services—whether for polio vaccine or contraception—are diverted for private gain at a terrible cost to millions of impoverished, largely illiterate, and uncomplaining people.
“Friends were worried that publishing the book might put me in danger,’ she admits. “But I didn’t name names and everything I have written is well known—just never described in such detail.”
The Heartfile Health Financing plan started with the royalties from Choked Pipes and the support of the Rockefeller Foundation. It also gets funding from the Clinton Global Initiative, the World Bank supported Pakistan Poverty Alleviation Fund, and the Sulemanivah Trust. Her key aim is to leverage the transparency of mobile phone technology to promote equity and quality in health systems. “On the one hand everyone, including the patient, will be able to watch the money. And as Heartfile expands, we aim to establish monitoring structures for compliance with ethical standards,” she explains.
Will it work? Zulfiqar Bhutta, professor of paediatrics at the Aga Khan University Medical Centre in Karachi, is optimistic that Nishtar’s project has indeed started “to break the log-jam in reaching the very poor. The elements of transparency, rapidity of access, and data monitoring make this a promising new intervention,” he says.
Rafat Atun, professor of international health management at Imperial College, London, who is due to evaluate the system, is already impressed by an innovative approach to targeting the poorest. “Mobile telephony will guarantee privacy, confidentiality, and an unprecedented access between patient and provider,” he says.
Cite this as: BMJ 2012;345:e5156
Competing interests: The author has completed the ICMJE unified disclosure form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declares no support from any organisation for the submitted work; no financial relationships with any organisation that might have an interest in the submitted work in the previous three years; and no other relationships or activities that could appear to have influenced the submitted work.
Provenance and peer review: Commissioned; not externally peer reviewed.